HospitalInspections.org

Based on observation it was determined the Facility failed to maintain the building physical structure, environment and equipment in a state of good repair in two (patient rooms #36 and #44) of three areas observed. The failed practice had the potential to affect all patients, staff, and visitors due to the potential for possible injury and infection control issues. Findings follow:

A. While on tour of the facility on 07/11/2017 at 1440, it was observed broken and chipped laminate on the window sill of room #44.
B. While on tour of the facility on 07/11/2017 at 1445, it was observed paint peeling on the window sill of room #36.
C. During the tour the Plant Maintenance Director verified the failed practices.

Based on observation, review of manufacturer storage guidelines, review of Pharmacy Policy PD-19, and interview, the facility failed to ensure 2 of 2 multiple dose vials (MDV) of Succinylcholine 10 milliliters (ml) did not exceed 14 days stored at room temperature once removed from refrigeration by assigning expiration dates that exceeded 14 days. In addition, the facility failed to ensure 1 of 6 unopened MDV of Rocuronium Bromide 5ml did not exceed 60 days stored at room temperature once removed from refrigeration by not assigning an expiration date. The deficient practice regarding Succinylcholine and Rocuronium Bromide was observed on 1 of 1 anesthesia cart containing the medications. The potential existed for the medications to have a decrease in potency and could affect all patients in which the medications were administered in that desired effects would not be achieved. Findings follow:

A. A tour of Surgery was conducted on 07/11/17 at 1335. Succinylcholine 10ml amd Rocuronium Bromide 5ml were obsereved stored on one anesthesia cart located in Operating Room #2 at room temperature. Two MDV of Succinylcholine 10ml placed on the anesthesia cart on 07/11/17 had assigned expiration dates of 08/01/17 which exceeded the allowed time (14 days) to be stored at room temperature by 7 days. One unopened MDV of Rocuronium Bromid 5ml was observed without an assigned expiration date to prevent storage at room temperature for greater than 60 days.
B. A review of manufacturer storage guidelines for Succinylcholine and Rocuronium Bromide was conducted on 07/12/17 at 1000. Storage guidelines for Succinylcholine revealed MDV of the medication could only be stored at room temperature for 14 days once removed from refrigeration to prevent any significant loss of potency. Manufacturer storage guidelines for Rocuronium Bromide revealed unopened MDV of the medication could be stored for 60 days at room temperature or opened MDV for 30 days once removed from refrigeration to prevent loss of potency.
C. Pharmacy Policy PD-19 was reviewed on 07/12/17 at 1355. The policy stated "Medications are stored under proper conditions as stated by the medication manufacturer to assure stability of that medication."
D. An interview was conducted with the Nurse Manager of Surgical Services on 07/11/17 at 1340. Through interview, it was verified the two MDV of Succinylcholine 10ml had been assigned expiration dates that exceeded 14 days allowed by the manufacturer to be stored at room temperature once removed from refrigeration. In the same interview, it was verified one MDV of Rocuronium Bromide 5ml had not been assigned an expiration date to prevent the medication from being stored at room temperature for greater than 60 days once removed from refrigeration.

Based on observation, interview and review of policy and procedure it was determined the facility failed to ensure in two of two (Pre-operative/Recovery room, Endoscopy room) areas: privacy curtains were clean and free of visible soil; bedside tables were free of dust and sticky residue; stretchers were free of tape and extra gloves, single use items were discarded after use; and single use sterile water for irrigation was discarded after opening. It could not be assured sources and transmission of infections could be prevented. The failed practice was likely to affect any patient who had surgery. The findings were:

A. The Nurse Manager of Surgical Services identified the Pre-Operative/Recovery Room as clean and ready for patient use at the time of observation. Observation of Bays #1-#3 in the Pre-operative/Recovery Room on 07/11/17 at 1310 revealed:
1) Three of three privacy curtain dividers between bays #1 - #3 had multiple areas of blue lines that resembled ink marks. The privacy curtain divider between bay #1 and #2 had an area of dark red dots and splatter marks.
2) Two of two (Bay #1 and #3) bedside tables had an accumulation of dust on the surfaces. Bay #1 bedside table had a sticky residue in the top drawer.
3) Bay #2 stretcher had tape on the frame and a glove draped on the rail beneath the mattress.
4) The findings were confirmed at the time of observation by the Nurse Manager of Surgical Services.
5) One of one Yankauer suction package open and resting on the suction equipment in the Pre-operative/Recovery Area Bay #1. Review of the manufacturer's label revealed content of the package was sterile unless open and single use only. The finding was confirmed at the time of observation by the Nurse Manager of Surgery.

B. The policy #IC-15 for laundering privacy curtains was received from the Clinical Nurse Manager for Surgical Services on 07/12/17 at 1332. Review of the policy revealed "Purpose: "To clearly define routine laundering of SCU and recovery room Privacy Curtain Dividers" The procedure listed "The task is to be performed the first Friday of every month." "Exceptions: If the Privacy Curtains become visibly soiled prior to scheduled time, the curtains are to be laundered at that time and then resume the usual schedule."

C. The Nurse Manager of Surgical Services stated on 07/11/17 at 1332 the privacy curtains were laundered when visibly soiled and that housekeeping was responsible for cleaning the curtains and the furnishings of the Pre-operative/Recovery room.

D. Observation on 07/11/17 at 1337 revealed one 250 milliliter, one 1500 milliliter and one 1000 milliliter sterile water for irrigation on the endoscopy cart in the Endoscopy room. The sterile water bottles for irrigation were opened and partially used. Review of the manufacturer's label revealed the product had no antimicrobial and was single use only. The finding was confirmed on 07/11/17 at 1340 by the Nurse Manager of Surgery.


Based on observation, review of policy and Association of periOperative Registered Nurses (AORN) guidelines and interview, it was determined the facility failed to ensure likely sources of infection were controlled in that clean surgical attire was not worn into the restricted areas of the operating room suite, and food was open and being eaten in the surgery restricted area by one of one (#1) Certified Registered Nurse Anesthetist (CRNA) observed. Failure to wear clean surgical attire (scrub attire that had not been previously worn) and prevent food consumption in the semi-restricted and restricted areas of surgery, did not assure surgical patients and staff would be protected from likely sources of infection. The failed practice was likely to affect all surgical patients on 07/12/17 and all patients treated by CRNA #1. The findings were:

A. Observation on 07/12/17 at 1051 revealed Certified Registered Nurse Anesthetist (CRNA) #1 entered the facility from outside wearing scrubs, surgical hat and eating a food bar. CRNA #1 was constantly observed as he entered the building and then walked into the surgical services area, passed the line that a required adherence to surgical attire and directly into the endoscopy room wearing the same scrubs, hat and eating a food bar. CRNA #1 was questioned by Surveyor #1 and stated he had just come from another facility and he was just finishing up the food.

B. Review of Surgical Services Policy 07/12/17 revealed clean surgical attire is to be worn by staff in the semi-restricted and restricted areas of the surgical suite. and food must not be taken into the semi-restricted and restricted areas of the surgical suite.

C. Review of AORN "Guideline for Surgical Attire," I.b.1 revealed "Scrub attire should be donned in a designated dressing area before entry from the outdoors into the semi-restricted and restricted areas. Changing from street apparel into clean or disposable scrub attire in a designated area assists in maintaining a clean environment and decreases the possibility of transferring microorganisms from street apparel to patients." Review of the AORN "Guideline for Prevention of Transmissible Infections," V.b revealed "Food and drink must not be taken into the semi-restricted or restricted areas of the perioperative suite. Food and drink must not be kept in refrigerators, freezers, shelves, or cabinets or on counter tops or work spaces where blood or other potentially infectious materials are present."

D. The Director of Nursing Services stated in an interview on 07/12/17 at 1210 that CRNA staff know they are to change scrubs and not eat in restricted areas. The Director of Nursing Services stated the Nurse Manager of Surgical Services had spoken to CRNA #1 and he had changed scrubs before the procedure on 07/12/17.

E. The Nurse Manager of Surgical Services was interviewed on 07/12/17 at 1330 and stated she had spoken to CRNA #1 and he had changed scrubs prior to the first procedure on 07/12/17. Confirmed at the time of interview that clean surgical attire is to be worn and no food is allowed in the restricted areas.


Based on observation, review of logs, policies and procedures, manufactures instructions for use (MIFU) and interview, it was determined the facility failed to assure patients would be protected from likely sources of infection in that Cidex OPA Solution Test Strip monitoring strips were not discarded within 90 days of opening; the lot number of the test strip bottle in use was not documented and the minimum effective concentration (MEC) was not tested prior to each use. Failure to follow MIFU for Cidex OPA Solution Test Strip monitoring did not assure the Cidex OPA solution would be effective for high level disinfection with each use. The failed practice affected all patients who had an endoscopy at the facility.

A. Review of the MIFU on 07/11/17 revealed "Cidex OPA solution Test Strips are developed exclusively for monitoring the minimum effective concentration (MEC) of CIDEX OPA Solution. It is recommended that CIDEX OPA Solution be tested before each usage with the CIDEX OPA Solution test strips in order to guard against dilution, which may lower the ortho-phthalaldehyde level of the solution below its MEC of 0.3%." "Do not use any remaining strips 90 days after opening the bottle."

B. Observation of the Endoscope Reprocessing Room on 07/11/17 at 1345 and 07/13/17 at 0900 revealed one open Cidex OPA solution test strip bottle. The lot number on the bottle was 029813, date opened 04/05/17, do not use after date 08/28/17 and the manufactures expiration date was 08/28/17. Review of the "Cidex OPA Strips QC Log" revealed the expired test strips had been used on 07/06/17, 07/10/17 and 07/13/17, which was 9 days beyond the manufactures 90 day limit for use once the bottle is opened.

C. The Nurse Manager of Surgery and Surgical Technician #1 were interviewed on 07/13/17 at 0918 and confirmed the findings in (A) and (B).

D. Review of the documentation on the "Cidex OPA Strips QC Log" on 07/11/17 and 07/13/17 revealed the Cidex OPA Solution Test Strip date opened was listed as 03/06/17 and the expiration date was 09/01/17 for 38 of 38 entries from 04/05/17 through 07/13/17. The date opened and manufactures expiration date on the log did not match the bottle in use at the time of observation as listed in (B).

E. In the presence of the Nurse Manager of Surgery, Surgical Technician #1 was interviewed on 07/13/17 at 0918 and confirmed the bottle in use since 04/05/17 was lot #029813 and that testing of the solution was done one time per day, not prior to each use. Surgical Technician #1 stated "I guess I just wrote it down wrong."

F. Review on 07/13/17 at 1310 revealed the most recent training for Surgical Technician #1 for Cidex OPA solution test strip monitoring was 10/05/09. The training and policy for use listed "The Cidex has to be checked before every scope using the Cidex OPA solution Test strips. The results must be marked in the book and initialed for every scope." This was confirmed by the Nurse Manager of Surgery on 07/13/17 at 1310.

Based on review of physicist report and interview, it was determined the facility failed to assure radiology equipment was inspected on an annual basis. The failed practice did not ensure patients would be protected from likely sources of harmful or excessive radiation in the event of equipment failure or malfunction. The failed practice was likely to affect all patients who had an x-ray. The findings were:

A. Review of the last physicist report revealed a date of 01/27/16.
B. The Radiology Department Manager confirmed on 07/12/17 at 1350 that 01/27/16 was the most recent date of radiology equipment inspection and stated the physicist comes one time per year.

Based on review of licensure for Rehabilitation Therapy Services and interview, the facility failed to have a mechanism in place to ensure one of one Speech Pathologist had current licensure and Tuberculosis screening. The potential existed for the facility to be be utilizing unlicensed personnel and personnel that had not been screened for Tuberculosis. Findings follow:

A. On 07/11/17, 07/12/17, and 07/13/17, current licensure and Tuberculosis screening had been requested for the one Speech Pathologist. Current licnesure and Tuberculosis screening were not presented.
B. An inteview was conduct with the RN for Quality Management on 07/13/17 at 1130 to ascertain whether the requested information had been provided by Rehabilitation Therapy Services. The interview revealed the information had not been provided.

Based on review of policy, dentist contract, credentials and interview, it was determined the facility failed to have a contract with a dentist or have a dentist on staff to provide for the emergent dental needs of patients in a Swing-bed. The failed practice did not ensure the emergency dental needs of patients in a swing-bed would be met. The failed practice was likely to affect the 07/11/17 patient census of one and any patient admitted to swing-bed status. The findings were:

A. Review of the Swing-Bed Policy and Procedure Manual revealed an approval date of 01/01/2017. Review of the Swing-bed Policy "Dental Services" revealed "The facility must ensure that a dentist is available for residents. They can satisfy this requirement by employing a staff dentist or having a contract/arrangement with a dentist to provide services." The dentist listed on the policy was Dentist #1.

B. Review of the contract and credentials for Dentist #1 revealed his state licensed expired on 12/31/15. The most recent Approval of Reappointment provided for Dentist #1was dated 09/25/1996.

C. The Nurse Manager for Swing-bed was interviewed on 07/13/17 at 0845 and confirmed the Dentist credentials were expired and there was no other dentist on staff or contracted at this time.

D. The Administrative Assistant was interviewed on 07/16/17 at 1115 and confirmed Dentist #1 had a licensed that expired on 12/31/15 and that there was no other dentist on staff or contracted at this time to provide for the emergency dental needs of Swing-bed patients.